19 April 2008

In the interests of his own safety Dr Grumble was not planning to post anything new. But Mrs Grumble is so dismayed by the polyclinic developments that, despite the risks, she has encouraged a new post on the topic. So what is there new to post about? One thing is the views of the NHS Confederation who seem to have hurriedly brought out a publication on the topic. It's of great interest to Dr Grumble who wonders just what is driving this frenzied imposition of polyclinics. Of course, what the NHS Confederation say and what the real drivers are might be quite different. Curiously, the box at the very top of the Introduction to Ideas from Darzi: polyclinics reads:

This is odd. First, because the document is called 'Ideas from Darzi' and this box reveals that it is not Darzi's idea at all. (Not that anybody thought it was.) And second, because the fact that everybody else is doing this does not mean that it is the right thing for British patients who, until recently, had the best primary care service in the world. Certainly this box is no justification whatsoever for polyclinics. It is plainly not intended for the discerning reader.

But don't worry because, according to the Confederation, the design rules that underlie the idea of the polyclinic appear to be 'fairly uncontroversial'. What are these fairly uncontroversial design rules? And, if they are uncontroversial, why is there such an outcry about polyclinics and why are they being imposed in such a heavy handed manner? If these Darzified clinics are so very wonderful why are we not all clammering for them?

The first wonderful thing about these clinics is that they will produce larger groupings of primary care professionals. Note they say 'primary care professionals'. You need to read these documents carefully. You are probably intended to think they mean doctors. But that is not what the document says. Draw your own conclusion.

Second these clinics will exploit 'economies of scale'. The relevant paragraph is short but examples given include the 'highlights of improved telephone booking'. Come on! And better access for those with learning disabilities and the mentally ill. To Dr Grumble this doesn't even sound faintly plausible. If you put more GPs (sorry - primary care professionals) together then patients with disabilities are less likely to have a GP close to where they live. These claims are disingenuous.

Third we are told the need for patients to travel to hospital will be reduced by 'relocating high volume work'. We are not given examples. One would think that high volume work, being high volume, can already be done in a group practice. The care of asthmatics, diabetics and the like would seem to be examples. So what are the conditions that polyclinics can deal with that current GPs (sorry - primary care professionals) cannot? Probably they exist but we are not told. Instead, in a very short paragraph we learn from 'Bunny Hill Primary Care Centre' that patients prefer a 'non-hospital setting' - which makes one think that perhaps they might like their current GPs' surgery. After all polyclinics do sound rather polyclinical.

Fourth we learn that polyclinics will break down the 'traditional barrier' between primary and secondary care. An example is how in Sunderland a shared approach has reduced unnecessary dermatological surgery. Now that is interesting. How could that happen? Could it be that GPs were cutting too many harmless lesions off? That doesn't sound like a very good argument for encouraging GPs to do more. But there is no reference so perhaps this interpretation is wrong.

Fifth we learn that space will be made for other services:

community health services

other related health services

social care services

leisure services

housing services

benefits services

Then there is another box which is presumably to enhance some key point, some killer fact. Here it is:

Here we have the implied allegation that nobody cares about the time the patient has to spend and that polyclinics would be much better. But it's nonsense isn't it? The polyclinic is more likely to be further away from the patients home. How are the elderly and disabled supposed to get there? Why this apparent interest in the young commuter? Could it be that they have money to spend on additional services in the polyclinic? But what about the killer fact in this box which is of course all the money spent on travelling to the hospital and on hospital car parking (who imposed this by the way?) all apparently because GPs cannot take blood. Come on. Mrs Grumble retired from inner city general practice 15 years ago and she cannot remember a practice that did not have a service which sped blood samples to the local hospital.

Of course, there are many arguments (pdf) against the polyclinic idea. Here Dr Grumble was just trying to grasp from the NHS Confederation the points in favour. Sadly there don't really seem to be any. None convincing anyway.

Who are these people in the NHS Confederation with such a great misunderstanding of primary care? Do they really have the interests of our patients at heart?

Posted by
Dr Grumble

15 comments:

Anonymous
said...

Polyclinics! The concept appears good but in reality it will not deliver locally targeted healthcare services as the patients you are trying to help will find it difficult to travel long distance to access services, personal one to one care will disappear and group care will become a buz word and you will become a number instead of an individual.

Personalised service will disappear. Sorry to say but small local specialised services will always outperform groups and deliver better one to one personal service where an individual has self respect and an identity.

A polyclinic appears to be coming to a street near me here in the outer edge of the inner city in place of an old DGH. It is within easy walking distance (as in a few hundred metres) of at least 5 of the local gp practices on the main bus route through our urban "village". I am hoping that it will do blood tests all day every day instead of only on Wednesday mornings at one of the health centres (this apparently imposed by the PCT), urine tests after noon (otherwise allegedly and unbelievably not enough time to get them to the testing place), tb jabs (local hospital 2 bus rides one way if they remember to actually book you in despite endless calls from the GP) and neonatal hearing tests (3 bus rides the other) but leave my excellent GP alone albeit maybe in a different room. However I can't quite see it working like that....

These things are not always carefully thought through. Quite a lot of the current developments are being madly rushed through because when the government wants something done the early birds always get more resources. It's one of the many tricks government uses to make things happen.

To me, what I find worrying about polyclinics is what Lord Darzi said re 'ending the doctor/patient 'fantastic' relationship. Of course, Polyclinics will do just that as they will be too impersonal, if only because of their size as well as the large number of staff working in them. I can predict that after the initial attention given to those using them, real patients as well as those who do not open up eaily will just lose out simply because they will be lost in the crowd. Some people shy away from opening up or undressing, even in front of a doctor they trust and have known for years, the reason why I can not see those being half at ease with total strangers working in large numbers and on shifts inside huge polyclinics.

I am one of those who very much values the trust or 'fantastic' doctor patient relationship and believe it to be part of the treatment and the cure. The idea of running medicine like you run a supermarket will harm many people who will probably stop going to the doctor when they should.

Of course S you are right. The special GP doctor patient relationship will be lost. We know patients prefer to see the same doctor but the relationship is also of value the other way around. These points and others are made in documents on the NHS confederation web site but they chose to be highly selective in their latest missive. They have, you see, an agenda.

By the way where Doc G works we are already running with the 'ideas from Darzi' as fast as we can. You see magically there is money for them. If you need another consultant they will say bad luck. But if you need another consultant to spend half time in the community the money drops from the sky. That's how governments make things happen. And that's how they waste money. At the end of the day there will be gleaming new polyclinics in marginal constituencies. Smiling politicians will be photographed standing before these gleaming monuments. But the patients will not be any happier with their GP because (contrary to what he government would have you believe) they are pretty happy already.

Dr Grumble is right. I have commented in the past that they could hardly have found a less qualified person to advise on restructuring of GP services. Mr Ara Darzi will, quite quickly, become a name like Dr Beeching which is associated with stupid ideas rushed through by a Stalinist Government.

They do not understand General Practice; they are, however, doing their very best to destroy it.

Very sad. Of couse these centres will be mainly manned by more and more nurses. It is clearly an attempt to push anyone who can afford to, to get private insurance. For those who can't, it's bring'em in, churn'm out production line or just let nature take it's course!

They think those huge impersonal centres will save money but wait and see because they will end up costing loads more than the current system. Expect lots of litigation and lots more abuse.

And, why are we being Americanised anyway?! ... When the Americans are now mostly in favour of a system similar to ours!

Doctor training has been messed up, now the whole of health will be messed up!

... and I don't believe what the conservatives say, in your latest link, they will do to stop this craze either. Actually, I don't believe in any of this lot anymore ... I have decided that it is safer to vote for the Looney Party! At least they know they are foolish ..

I fear, S, you are right. My own suspicion is that all this is being driven by big business which invests enormous sums trying subtly and not so subtly to get government to do what they want. New Labour has shown no suspicion of their blandishments. The Conservatives are even more likely to kow tow to the demands of business.

The involvement, Jobbing Doctor, of Darzi who plainly does not have the right background to be reorganising general practice is interesting. Over a year ago I heard from no less a person than Bill McCarthy (Director-General of Policy and Strategy at the DoH) that politicians are frustrated and baffled by the lack of gratitude from clinicians and the public. They are well aware that they are much less popular than doctors. I wonder if this may be why they set out to dupe Darzi into acting as the political mouthpiece. They obviously didn't have enough nous to realise that an academic surgeon might not have been the ideal choice.

'all this is being driven by big business which invests enormous sums trying subtly and not so subtly to get government to do what they want'

No subtlness about any of this Dr G. Everyone knows 'exactly' what they are doing (remember Simon Stevens and Darzi's admiration of his 'talents?')

As for the government, it simply wants to rid itself of the headache of having to finance and manage the NHS. Basically, the politicians are not business men and they have tried and they have failed so they decided it was best to pass the problem to those who know how, regardless of the consequences .. Let the sharks do the worrying and let the sharks reap the profits. If the poor end up suffering in the process, no big deal, they were born into suffering anyway! ... and they are unlikely to object, because the majority do not understand and will probably even like the virgin receptionist in her red uniform in that fancy building .. It may even resemble going private; the dream of everyone who can not afford the luxury. GP surgeries were, not so long ago, described as 'the sole practitioners practicing at the back of a victorian terrace', Contrast that with Virgin and his stewardess like polyclinic 'crew!'

What the politicians are not taking into account is that the sharks are driven by money alone and will play both sides, the government as well as the patients for maximum gain. So, there will be no getting rid of the headache at the end but much more of it IMO.